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LOUISIANA CVS PHARMACY, L.L.C.
DSH190002 LAFAYETTE GENERAL MEDICAL CENTER
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Covered Entity Details
Entity Name
LAFAYETTE GENERAL MEDICAL CENTER
Subdivision Name
Type
Disproportionate Share Hospital
340B ID
DSH190002
Entity Address
1214 COOLIDGE STREET
LAFAYETTE, LA 70503
Medicare Provider Number
190002
Participating Start Date
10/25/2005
Last Recertification Date
9/3/2024
Pharmacy Details
Pharmacy Name
LOUISIANA CVS PHARMACY, L.L.C.
Pharmacy Address
DBA: CVS/PHARMACY # 01579
6800 JOHNSTON ST.
LAFAYETTE, LA 70503
Pharmacy Comments
Contract Details
Approval Date
7/9/2013
Contract Begin Date
10/1/2013
Carve-In Effective Date
Contract Comments
Contacts
Covered Entity Signing Official
PATRICK GANDY, CEO
(337) 289-7475
Contract Pharmacy Representative
CVS Caremark
Anthony Gratto, 340B Vendor Manager
(401) 770-7298
Signed By Date
7/9/2013
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